CPD: Essential tremor – recognition, assessment and management in primary care

In our latest CPD module, GP Dr Roger Henderson outlines the features, causes and management strategies for essential tremor, and explains how nurses in general practice and the community can support patients living with this common movement disorder. Read the full module on Nursing in Practice 365 today.

Essential tremor is the most common pathological tremor in humans and one of the most frequent movement disorders encountered in clinical practice. It is characterised by rhythmic, involuntary shaking – most often of the hands and forearms – that occurs during voluntary movement or when maintaining a posture. Although classically considered a benign condition, essential tremor can cause significant functional impairment, embarrassment, anxiety and reduced quality of life.

In the UK, essential tremor affects around one million people, but the condition is under-recognised and often misdiagnosed as Parkinson’s disease. Nurses in general practice and the community play a key role in identifying early symptoms, supporting diagnostic assessment, educating patients and optimising lifestyle and pharmacological management.

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This module provides an evidence-based overview of essential tremor, including the clinical presentation and key principles of diagnosis and management, drawing on current NICE guidance and best-practice recommendations.

Learning objectives

By the end of this module, you should be able to:

• Define essential tremor and differentiate it from other causes of tremor.
• Describe the epidemiology and potential genetic and environmental risk factors.
• Recognise the key clinical features and patterns of tremor presentation.
• Take an evidence-based approach to assessment and diagnosis in primary care.
• Discuss pharmacological and non-pharmacological management options, including when to refer to neurology.
• Provide practical lifestyle and psychosocial advice to support individuals living with essential tremor.

Definition

Essential tremor is defined as a chronic, often progressive neurological disorder characterised by bilateral, largely symmetric, action tremor of the hands and forearms, in the absence of other neurological signs.

An action tremor is a tremor that occurs in a part of the body when a person is intentionally moving it or holding it in a posture. This is distinct from a resting tremor which occurs when the body part is at rest.

Traditionally, essential tremor was viewed as a benign condition involving isolated tremor of the upper limbs. However, it is now recognised as a syndrome that can involve tremor elsewhere such as the head, voice, jaw and legs and may be accompanied by subtle gait, cognitive or mood disturbances.

Epidemiology

Essential tremor is the most prevalent movement disorder worldwide. Prevalence estimates vary between studies, but the overall prevalence is thought to be around 1–2% of the general population, while the rate of essential tremor increases with age, affecting up to 4–5% of people over 65 and 20% of those over 95. It affects men and women equally and around 50% of cases are inherited, with an autosomal dominant inheritance pattern, often termed familial essential tremor.

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Essential tremor is underdiagnosed and many individuals attribute symptoms to ageing or stress and do not seek medical help until the tremor interferes with their daily activities.

Pathophysiology

The exact pathophysiology remains incompletely understood, but patients appear to have abnormal cerebellar function. Imaging studies implicate the cerebellum, red nuclei and inferior olivary nuclei, areas of the brain associated with motor coordination, suggesting their involvement as either a cause or a result of the tremor.

Exposure to certain compounds or elements including beta-carboline alkaloids (found in tobacco and certain foods), lead and organic solvents has also been suggested as possible environmental triggers, although evidence remains inconsistent.

Clinical presentation

Typical features

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• An action tremor appears during voluntary movement (e.g., writing, drinking, using utensils) or when holding a posture (e.g., arms outstretched).
• The tremor is usually bilateral and most prominent in the hands and forearms.
• A head and voice tremor is common in longstanding disease.
• There is no resting tremor – the tremor subsides when muscles are fully relaxed. (This is an important diagnostic point).
• The tremor typically subsides with a small amount of alcohol – a characteristic but non-specific feature.
• It is worsened by stress, fatigue, caffeine, anxiety and certain medications such as beta-adrenergic agonists (such as salmeterol and formoterol asthma medications) and antidepressants.
• Other neurological signs are absent. This helps to distinguish an essential tremor from Parkinson’s disease.

Click here to complete the full module and log 1.5 CPD hours towards revalidation